Magnetic resonance imaging of implanted deep brain stimulators: experience in a large series

Simultaneous cortical, subcortical, and brainstem mapping of sensory activation

Non-painful tactile sensory stimuli are processed in the cortex, subcortex, and brainstem. Recent functional magnetic resonance imaging (fMRI) studies have highlighted the value of whole-brain, systems-level investigation for examining pain processing. However, whole-brain fMRI studies are uncommon, in part due to challenges with signal to noise when studying the brainstem. Furthermore, the differentiation of small sensory brainstem structures such as the cuneate and gracile nuclei necessitates high resolution imaging. To address this gap in systems-level sensory investigation, we employed a whole-brain, multi-echo fMRI acquisition at 3T with multi-echo independent component analysis (ME-ICA) denoising and brainstem-specific modeling to enable detection of activation across the entire sensory system. In healthy participants, we examined patterns of activity in response to non-painful brushing of the right hand, left hand, and right foot, and found the expected lateralization, with distinct cortical and subcortical responses for upper and lower limb stimulation. At the brainstem level, we were able to differentiate the small, adjacent cuneate and gracile nuclei, corresponding to hand and foot stimulation respectively. Our findings demonstrate that simultaneous cortical, subcortical, and brainstem mapping at 3T could be a key tool to understand the sensory system in both healthy individuals and clinical cohorts with sensory deficits.

Day one postoperative MRI findings following electrode placement for deep brain stimulation: analysis of a large case series

Objective

This study sought to characterize postoperative day one MRI findings in deep brain stimulation (DBS) patients.

Methods

DBS patients were identified by CPT and had their reviewed by a trained neuroradiologist and neurosurgeon blinded to MR sequence and patient information. The radiographic abnormalities of interest were track microhemorrhage, pneumocephalus, hematomas, and edema, and the occurrence of these findings in compare the detection of these complications between T1/T2 gradient-echo (GRE) and T1/T2 fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) sequences was compared. The presence, size, and association of susceptibility artifact with other radiographic abnormalities was also described. Lastly, the association of multiple microelectrode cannula passes with each radiographic finding was evaluated. Ad-hoc investigation evaluated hemisphere-specific associations. Multiple logistic regression with Bonferroni correction (corrected p = 0.006) was used for all analysis.

Results

Out of 198 DBS patients reviewed, 115 (58%) patients showed entry microhemorrhage; 77 (39%) track microhemorrhage; 44 (22%) edema; 69 (35%) pneumocephalus; and 12 (6%) intracranial hematoma. T2 GRE was better for detecting microhemorrhage (OR = 14.82, p < 0.0001 for entry site and OR = 4.03, p < 0.0001 for track) and pneumocephalus (OR = 11.86, p < 0.0001), while T2 FLAIR was better at detecting edema (OR = 123.6, p < 0.0001). The relatively common findings of microhemorrhage and edema were best visualized by T2 GRE and T2 FLAIR sequences, respectively. More passes intraoperatively was associated with detection of ipsilateral track microhemorrhage (OR = 7.151, p < 0.0001 left; OR = 8.953, p < 0.0001 right). Susceptibility artifact surrounding electrodes possibly interfered with further detection of ipsilateral edema (OR = 4.323, p = 0.0025 left hemisphere only).

Discussion

Day one postoperative magnetic resonance imaging (MRI) for DBS patients can be used to detect numerous radiographic abnormalities not identifiable on a computed tomographic (CT) scan. For this cohort, multiple stimulating cannula passes intraoperatively was associated with increased microhemorrhage along the electrode track. Further studies should be performed to evaluate the clinical relevance of these observations.

No Adverse Effects following Off-Label Magnetic Resonance Imaging in a Patient with Two Deep Brain Stimulation Systems: A Case Report

Magnetic resonance imaging (MRI) in patients with implanted deep brain stimulation (DBS) systems is subject to strict guidelines in order to ensure patient safety. Criteria include limits on the number of implanted leads. Here, we describe the case of a 29-year-old patient with generalized dystonia implanted with 4 DBS electrodes and 2 implantable pulse generators, who had an off-label spinal MRI without regard for manufacturer guidance yet suffered no adverse effects. This suggests that manufacturer guidelines might be overly restrictive with regards to limits on implanted DBS hardware. Further research in this area is needed to widen access to this fundamental imaging modality for patients with DBS.

Evaluating the Safety of Simultaneous Intracranial Electroencephalography and Functional Magnetic Resonance Imaging Acquisition Using a 3 Tesla Magnetic Resonance Imaging Scanner

Background

The unsurpassed sensitivity of intracranial electroencephalography (icEEG) and the growing interest in understanding human brain networks and ongoing activities in health and disease have make the simultaneous icEEG and functional magnetic resonance imaging acquisition (icEEG-fMRI) an attractive investigation tool. However, safety remains a crucial consideration, particularly due to the impact of the specific characteristics of icEEG and MRI technologies that were safe when used separately but may risk health when combined. Using a clinical 3-T scanner with body transmit and head-receive coils, we assessed the safety and feasibility of our icEEG-fMRI protocol.

Methods

Using platinum and platinum-iridium grid and depth electrodes implanted in a custom-made acrylic-gel phantom, we assessed safety by focusing on three factors. First, we measured radio frequency (RF)-induced heating of the electrodes during fast spin echo (FSE, as a control) and the three sequences in our icEEG-fMRI protocol. Heating was evaluated with electrodes placed orthogonal or parallel to the static magnetic field. Using the configuration with the greatest heating observed, we then measured the total heating induced in our protocol, which is a continuous 70-min icEEG-fMRI session comprising localizer, echo-planar imaging (EPI), and magnetization-prepared rapid gradient-echo sequences. Second, we measured the gradient switching-induced voltage using configurations mimicking electrode implantation in the frontal and temporal lobes. Third, we assessed the gradient switching-induced electrode movement by direct visual detection and image analyses.

Results

On average, RF-induced local heating on the icEEG electrode contacts tested were greater in the orthogonal than parallel configuration, with a maximum increase of 0.2°C during EPI and 1.9°C during FSE. The total local heating was below the 1°C safety limit across all contacts tested during the 70-min icEEG-fMRI session. The induced voltage was within the 100-mV safety limit regardless of the configuration. No gradient switching-induced electrode displacement was observed.

Conclusion

We provide evidence that the additional health risks associated with heating, neuronal stimulation, or device movement are low when acquiring fMRI at 3 T in the presence of clinical icEEG electrodes under the conditions reported in this study. High specific absorption ratio sequences such as FSE should be avoided to prevent potential inadvertent tissue heating.

Therapeutic Devices for Motor Symptoms in Parkinson’s Disease: Current Progress and a Systematic Review of Recent Randomized Controlled Trials

Background

Pharmacotherapy is the first-line treatment option for Parkinson’s disease, and levodopa is considered the most effective drug for managing motor symptoms. However, side effects such as motor fluctuation and dyskinesia have been associated with levodopa treatment. For these conditions, alternative therapies, including invasive and non-invasive medical devices, may be helpful. This review sheds light on current progress in the development of devices to alleviate motor symptoms in Parkinson’s disease.

Methods

We first conducted a narrative literature review to obtain an overview of current invasive and non-invasive medical devices and thereafter performed a systematic review of recent randomized controlled trials (RCTs) of these devices.

Results

Our review revealed different characteristics of each device and their effectiveness for motor symptoms. Although invasive medical devices are usually highly effective, surgical procedures can be burdensome for patients and have serious side effects. In contrast, non-pharmacological/non-surgical devices have fewer complications. RCTs of non-invasive devices, especially non-invasive brain stimulation and mechanical peripheral stimulation devices, have proven effectiveness on motor symptoms. Nearly no non-invasive devices have yet received Food and Drug Administration certification or a CE mark.

Conclusion

Invasive and non-invasive medical devices have unique characteristics, and several RCTs have been conducted for each device. Invasive devices are more effective, while non-invasive devices are less effective and have lower hurdles and risks. It is important to understand the characteristics of each device and capitalize on these.

Safety of Intracranial Electroencephalography During Functional Electromagnetic Resonance Imaging in Humans at 1.5 Tesla Using a Head Transmit RF Coil: Histopathological and Heat-Shock Immunohistochemistry Observations

OBJECTIVES

Simultaneous intracranial EEG and functional MRI (icEEG-fMRI) recordings in humans, whereby EEG is recorded from electrodes implanted inside the cranium during fMRI scanning, were made possible following safety studies on test phantoms and our specification of a rigorous data acquisition protocol. In parallel with this work, other investigations in our laboratory revealed the damage caused by the EEG electrode implantation procedure at the cellular level. The purpose of this report is to further explore the safety of performing MRI, including simultaneous icEEG-fMRI data acquisitions, in the presence of implanted intra-cranial EEG electrodes, by presenting some histopathological and heat-shock immunopositive labelling observations in surgical tissue samples from patients who underwent the scanning procedure.

METHODS

We performed histopathology and heat shock protein expression analyses on surgical tissue samples from nine patients who had been implanted with icEEG electrodes. Three patients underwent icEEG-fMRI and structural MRI (sMRI); three underwent sMRI only, all at similar time points after icEEG implantation; and three who did not undergo functional or sMRI with icEEG electrodes.

RESULTS

The histopathological findings from the three patients who underwent icEEG-fMRI were similar to those who did not, in that they showed no evidence of additional damage in the vicinity of the electrodes, compared to cases who had no MRI with implanted icEEG electrodes. This finding was similar to our observations in patients who only underwent sMRI with implanted icEEG electrodes.

CONCLUSION

This work provides unique evidence on the safety of functional MRI in the presence of implanted EEG electrodes. In the cases studied, icEEG-fMRI performed in accordance with our protocol based on low-SAR (≤0.1 W/kg) sequences at 1.5T using a head-transmit RF coil, did not result in measurable additional damage to the brain tissue in the vicinity of implanted electrodes. Furthermore, while one cannot generalize the results of this study beyond the specific electrode implantation and scanning conditions described herein, we submit that our approach is a useful framework for the post-hoc safety assessment of MR scanning with brain implants.

Mapping Motor Pathways in Parkinson’s Disease Patients with Subthalamic Deep Brain Stimulator: A Diffusion MRI Tractography Study

Introduction

This study assessed the safety of postoperative diffusion tensor imaging (DTI) with on-state deep brain stimulation (DBS) and the feasibility of reconstruction of the white matter tracts in the vicinity of the stimulation site of the subthalamic nucleus (STN). The association between the impact of DBS on the nigrostriatal pathway (NSP) and the treatment effect on motor symptoms in Parkinson’s disease (PD) was then evaluated.

Methods

Thirty-one PD patients implanted with STN-DBS (mean age: 66 years; 25 male) were scanned on a 1.5-T magnetic resonance imaging (MRI) scanner using the DTI sequence with DBS on. Twenty-three of them were scanned a second time with DBS off. The NSP, dentato-rubro-thalamic tract (DRTT), and hyperdirect pathway (HDP) were generated using both deterministic and probabilistic tractography methods. The DBS-on-state and off-state tractography results were validated and compared. Afterward, the relationships between the characteristics of the reconstructed white matter tracts and the clinical assessment of PD symptoms and the DBS effect were further examined.

Results

No adverse events related to DTI were identified in either the DBS-on-state or off-state. Overall, the NSP was best reconstructed, followed by the DRTT and HDP, using the probabilistic tractography method. The connection probability of the left NSP was significantly lower than that of the right side (p < 0.05), and a negative correlation (r = −0.39, p = 0.042) was identified between the preoperative symptom severity in the medication-on state and the connection probability of the left NSP in the DBS-on-state images. Furthermore, the distance from the estimated left-side volume of tissue activated (VTA) by STN-DBS to the ipsilateral NSP was significantly shorter in the DBS-responsive group compared to the DBS-non-responsive group (p = 0.046).

Conclusions

DTI scanning is safe and delineation of white matter pathway is feasible for PD patients implanted with the DBS device. Postoperative DTI is a useful technique to strengthen our current understanding of the therapeutic effect of DBS for PD and has the potential to refine target selection strategies for brain stimulation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00331-1.

For some more seriously affected Parkinson’s disease (PD) patients, drugs are no longer effective in treating their symptoms. An alternate treatment is to use deep brain stimulation (DBS), a commonly used neurosurgical therapy for PD patients. For those DBS treatments targeting the subthalamic nucleus (STN), the electrical stimulation used may impact nearby white matter tracts and alter the effectiveness of the DBS treatment. The nigrostriatal pathway (NSP), dentato-rubro-thalamic tract, and hyperdirect pathway are three white matter tracts near the STN. They are all relevant to motor symptoms in PD. This study examined whether imaging these tracts using magnetic resonance imaging (MRI) is safe and feasible in the presence of DBS leads. The relationships between the fiber-tracking characteristics and distance to the DBS leads were then evaluated. For this purpose, 31 PD patients with stimulation-on were scanned on a 1.5 T MRI scanner using a diffusion tensor imaging sequence. A total of 23 subjects underwent another scan using the same sequence with stimulation-off. No adverse events related to diffusion tensor imaging were found. Among the white matter tracts near the STN, the NSP was best delineated, followed by the dentato-rubro-thalamic tract and the hyperdirect pathway. The connection probability of the left NSP was significantly lower than that of the right side as were the subject’s motor symptoms. The closer the distance between the NSP and the stimulation location, the better the DBS outcome. These findings indicate that imaging white matter tracts with DBS on is safe and useful in mapping DBS outcomes.

Rapid safety assessment and mitigation of radiofrequency induced implant heating using small root mean square sensors and the sensor matrix Qs

PURPOSE

Rapid detection and mitigation of radiofrequency (RF)-induced implant heating during MRI based on small and low-cost embedded sensors.

THEORY AND METHODS

A diode and a thermistor are embedded at the tip of an elongated mock implant. RF-induced voltages or temperature change measured by these root mean square (RMS) sensors are used to construct the sensor Q-Matrix (Q_S ). Hazard prediction, monitoring and parallel transmit (pTx)-based mitigation using these sensors is demonstrated in benchtop measurements at 300 MHz and within a 3T MRI.

RESULTS

Q_S acquisition and mitigation can be performed in <20 ms demonstrating real-time capability. The acquisitions can be performed using safe low powers (<3 W) due to the high reading precision of the diode (126 µV) and thermistor (26 µK). The orthogonal projection method used for pTx mitigation was able to reduce the induced signals and temperatures in all 155 investigated locations. Using the Q_S approach in a pTx capable 3T MRI with either a two-channel body coil or an eight-channel head coil, RF-induced heating was successfully assessed, monitored and mitigated while the image quality outside the implant region was preserved.

CONCLUSION

Small (<1.5 mm³ ) and low-cost (<1 €) RMS sensors embedded in an implant can provide all relevant information to predict, monitor and mitigate RF-induced heating in implants, while preserving image quality. The proposed pTx-based Q_S approach is independent of simulations or in vitro testing and therefore complements these existing safety assessments.

Imaging patients pre and post deep brain stimulation: Localization of the electrodes and their targets

PURPOSE

Deep brain stimulation (DBS) has become a widely performed surgical procedure for patients with medically refractory movement disorders and mental disorders. It is clinically important to set up a MRI protocol to map the brain targets and electrodes of the patients before and after DBS and to understand the imaging artifacts caused by the electrodes.

METHODS

Five patients with DBS electrodes implanted in the habenula (Hb), fourteen patients with globus pallidus internus (GPi) targeted DBS, three pre-DBS patients and seven healthy controls were included in the study. The MRI protocol consisted of magnetization prepared rapid acquisition gradient echo T1 (MPRAGE T1W), 3D multi-echo gradient recalled echo (ME-GRE) and 2D fast spin echo T2 (FSE T2W) sequences to map the brain targets and electrodes of the patients. Phantom experiments were also run to determine both the artifacts and the susceptibility of the electrodes. Signal to noise ratio (SNR) on T1W, T2W and GRE datasets were measured. The visibility of the brain structures was scored according to the Rose criterion. A detailed analysis of the characteristics of the electrodes in all three sequence types was performed to confirm the reliability of the postoperative MRI approach. In order to understand the signal behavior, we also simulated the corresponding magnitude data using the same imaging parameters as in the phantom sequences.

RESULTS

The mean ± inter-subject variability of the SNRs, across the subjects for T1W, T2W, and GRE datasets were 20.1 ± 8.1, 14.9 ± 3.2, and 43.0 ± 7.6, respectively. High resolution MPRAGE T1W and FSE T2W data both showed excellent contrast for the habenula and were complementary to each other. The mean visibility of the habenula in the 25 cases for the MPRAGE T1W data was 5.28 ± 1.11; and the mean visibility in the 20 cases for the FSE T2W data was 5.78 ± 1.30. Quantitative susceptibility mapping (QSM), reconstructed from the ME-GRE sequence, provided sufficient contrast to distinguish the substructures of the globus pallidus. The susceptibilities of the GPi and globus pallidus externa (GPe) were 0.087 ± 0.013 ppm and 0.115 ± 0.015 ppm, respectively. FSE T2W sequences provided the best image quality with smallest image blooming of stimulator leads compared to MPRAGE T1W images and GRE sequence images, the measured diameters of electrodes were 1.91 ± 0.22, 2.77 ± 0.22, and 2.72 ± 0.20 mm, respectively. High resolution, high bandwidth and short TE (TE = 2.6 ms) GRE helped constrain the artifacts to the area of the electrodes and the dipole effect seen in the GRE filtered phase data provided an effective mean to locate the end of the DBS lead.

CONCLUSION

The imaging protocol consisting of MPRAGE T1W, FSE T2W and ME-GRE sequences provided excellent pre- and post-operative visualization of the brain targets and electrodes for patients undergoing DBS treatment. Although the artifacts around the electrodes can be severe, sometimes these same artifacts can be useful in identifying their location.

Improving Safety of MRI in Patients with Deep Brain Stimulation Devices

MRI is a valuable clinical and research tool for patients undergoing deep brain stimulation (DBS). However, risks associated with imaging DBS devices have led to stringent regulations, limiting the clinical and research utility of MRI in these patients. The main risks in patients with DBS devices undergoing MRI are heating at the electrode tips, induced currents, implantable pulse generator dysfunction, and mechanical forces. Phantom model studies indicate that electrode tip heating remains the most serious risk for modern DBS devices. The absence of adverse events in patients imaged under DBS vendor guidelines for MRI demonstrates the general safety of MRI for patients with DBS devices. Moreover, recent work indicates that-given adequate safety data-patients may be imaged outside these guidelines. At present, investigators are primarily focused on improving DBS device and MRI safety through the development of tools, including safety simulation models. Existing guidelines provide a standardized framework for performing safe MRI in patients with DBS devices. It also highlights the possibility of expanding MRI as a tool for research and clinical care in these patients going forward.

Comparison of Intraoperative Computed Tomography Scan with Postoperative Magnetic Resonance Imaging for Determining Deep Brain Stimulation Electrode Coordinates

BACKGROUND

Deep brain stimulation (DBS) is an effective therapy for a variety of refractory movement disorders. Accurate lead placement in the target nucleus is critical to ensure therapeutic effects and to minimize side effects, and intraoperative computed tomography (iCT) scan has been used to target and confirm lead position. The objective of this study is to compare the accuracy of determining the x, y, and z coordinates of final lead placement using iCT scan relative to postoperative magnetic resonance imaging (MRI).

METHODS

We conducted a retrospective study on 83 patients who underwent insertion of 145 DBS leads from 2015 to 2017 at a single institution. iCT scan was merged with the preoperative MRI to determine lead coordinates on both magnetic resonance and computed tomography images independently, and the absolute differences between the x, y, and z coordinates between the 2 scans along with the Euclidean vectors were calculated.

RESULTS

The mean absolute differences ± standard error of the mean between iCT scan and postoperative MRI coordinates were as follows: x = 0.01 ± 0.09 mm (P = 0.89), y = 1.67 ± 0.14 mm (P < 0.001), and z = 2.75 ± 0.15 mm (P < 0.001). The average Euclidean vector difference was 3.21 ± 0.15 mm (P < 0.001).

CONCLUSIONS

Significant differences exist between iCT scan and postoperative MRI DBS y and z lead coordinates, but not with x coordinates. Based on this series, iCT scan is more accurate when confirming x coordinates, and less accurate for confirming y and z coordinates during DBS operations.

Safety assessment of spine MRI in deep brain stimulation patients

OBJECTIVE

Many centers are hesitant to perform clinically indicated MRI in patients who have undergone deep brain stimulation (DBS). Highly restrictive guidelines prohibit the use of most routine clinical MRI protocols in these patients. The authors' goals were to assess the safety of spine MRI in patients with implanted DBS devices, first through phantom model testing and subsequently through validation in a DBS patient cohort.

METHODS

A phantom was used to assess DBS device heating during 1.5-T spine MRI. To establish a safe spine protocol, routinely used clinical sequences deemed unsafe (a rise in temperature > 2°C) were modified to decrease the rise in temperature. This safe phantom-based protocol was then used to prospectively run 67 spine MRI sequences in 9 DBS participants requiring clinical imaging. The primary outcome was acute adverse effects; secondary outcomes included long-term adverse clinical effects, acute findings on brain MRI, and device impedance stability.

RESULTS

The increases in temperature were highest when scanning the cervical spine and lowest when scanning the lumbar spine. A temperature rise < 2°C was achieved when 3D sequences were modified to 2D and when the number of slices was decreased by the minimum amount compared to routine spine MRI protocols (but there were still more slices than allowed by vendor guidelines). Following spine MRI, no acute or long-term adverse effects or acute findings on brain MR images were detected. Device impedances remained stable.

CONCLUSIONS

Patients with DBS devices may safely undergo spine MRI with a fewer number of slices compared to those used in routine clinical protocols. Safety data acquisition may allow protocols outside vendor guidelines with a maximized number of slices, reducing the need for radiologist supervision.Clinical trial registration no.: NCT03753945 (ClinicalTrials.gov).

MRI in patients with implanted active devices: how to combine safety and image quality using a limited transmission field?

OBJECTIVES

Radio frequency (RF) pulses in magnetic resonance imaging (MRI) can interact with implanted devices and cause tissue damage. However, there are new devices that can safely perform measurements with liberal MRI conditions such as an RF transmission field B_1+rms ≤ 2.0 μT. We investigated whether MRI in this case is limited for these technical reasons.

METHODS

We selected typical MRI protocols of six body regions (brain, cervical spine, lumbar spine, knee, liver, heart) using two typical 1.5T MRI scanners. Overall, we adapted 62 sequences to B_1+rms conditions and evaluated their diagnostic quality. For this, we measured signal-to-noise-ratio (SNR), contrast-to-noise-ratio (CNR), and geometric deviation (GD) as quality parameters, using phantom studies. For questionnaire studies, we selected pairs of original and adapted sequences in healthy volunteers. Blinded radiologists rated the images as single sequence rating and in direct comparison.

RESULTS

Roughly one-third of the checked sequences were below the B_1+rms limit. Here, 56 of the 62 adapted sequences showed at least the same image quality in single ratings. A reduction in SNR and/or CNR was found with 31 sequences and only one sequence with considerably increased GD. Especially, sequences with original high B_1+rms values, PD sequences, and sequences of the Siemens knee and heart protocol were difficult to adapt, whereas most TSE and IR sequences had no clinical limitations.

CONCLUSION

By limiting the transmission field to B_1+rms ≤ 2.0 μT, clinically relevant MR sequences can be adapted with nearly no reduction in image quality. Despite limiting the transmission field, high-quality MR imaging is possible. We could derive strategies for adaptation.

KEY POINTS

• Despite limiting the transmission field, high-quality MRI is possible. • We could derive strategies for adapting the sequences to B_1+rms≤ 2.0 μT. • This enables high-quality MRI of different body regions for patients with AD.

Multi T1-weighted contrast MRI with fluid and white matter suppression at 1.5 T

INTRODUCTION

The fluid and white matter suppression sequence (FLAWS) provides two T1-weighted co-registered datasets: a white matter (WM) suppressed contrast (FLAWS1) and a cerebrospinal fluid (CSF) suppressed contrast (FLAWS2). FLAWS has the potential to improve the contrast of the subcortical brain regions that are important for Deep Brain Stimulation surgery planning. However, to date FLAWS has not been optimized for 1.5 T. In this study, the FLAWS sequence was optimized for use at 1.5 T. In addition, the contrast-enhancement properties of FLAWS image combinations were investigated using two voxel-wise FLAWS combined images: the division (FLAWS-div) and the high contrast (FLAWS-hc) image.

METHODS

FLAWS sequence parameters were optimized for 1.5 T imaging using an approach based on the use of a profit function under constraints for brain tissue signal and contrast maximization. MR experiments were performed on eleven healthy volunteers (age 18-30). Contrast (CN) and contrast to noise ratio (CNR) between brain tissues were measured in each volunteer. Furthermore, a qualitative assessment was performed to ensure that the separation between the internal globus pallidus (GPi) and the external globus pallidus (GPe) is identifiable in FLAWS1.

RESULTS

The optimized set of sequence parameters for FLAWS at 1.5 T provided contrasts similar to those obtained in a previous study at 3 T. The separation between the GPi and the GPe was clearly identified in FLAWS1. The CN of FLAWS-hc was higher than that of FLAWS1 and FLAWS2, but was not different from the CN of FLAWS-div. The CNR of FLAWS-hc was higher than that of FLAWS-div.

CONCLUSION

Both qualitative and quantitative assessments validated the optimization of the FLAWS sequence at 1.5 T. Quantitative assessments also showed that FLAWS-hc provides an enhanced contrast compared to FLAWS1 and FLAWS2, with a higher CNR than FLAWS-div.

Early detection of cerebral ischemic events on intraoperative magnetic resonance imaging during surgical procedures for deep brain stimulation

BACKGROUND

Although intracerebral hemorrhage is the most feared complication of deep brain stimulation (DBS) surgery, cerebral ischemic events in association with DBS surgery have only rarely been described. We therefore evaluated the role of intraoperative MRI (iMRI) for early identification of cerebral ischemic events during DBS procedures and determined how ischemic infarctions affect patients over acute and long-term periods.

METHODS

Between January 2010 and December 2017, 1160 DBS electrodes were implanted in 595 patients at Chinese People's Liberation Army General Hospital, with the help of iMRI. The iMRI was performed in all patients after implantation, to define the accuracy of lead placement and detect complications. A CT scan was performed on postoperative days 1 to 7.

RESULTS

The iMRI showed that cerebral ischemic changes happened in nine (1.51% of patients, 0.78% of leads) patients. Only two (0.34%) of nine patients had an ischemic infarction in the basal ganglia, while seven (1.18%) had cortical ischemia. Six (67%) of the nine patients had long-term complications, two with mild hemiparesis, two with seizures, one with language dysfunction, and one with memory loss. Of those with a cortical ischemic infarction, only three (42.86%) of seven patients had no long-term complications. Long-term follow-up imaging showed that not all the patients recovered normal morphological structure in the area of ischemic foci. The factors of sex, age, target, and anesthesia were not related to ischemic events. In six (66.7%) cases, the entry point on the cortex or the path was not ideal.

CONCLUSIONS

Intraoperative ischemic events are not uncommon in DBS surgery. Ischemia can cause serious permanent complications, and regions subject to severe ischemia cannot be restored; it is therefore necessary to pay careful attention to any signs of ischemia. iMRI objectively provides the basis for early diagnosis of intraoperative ischemic infarction, providing guidance for follow-up treatment. The deviation in the entry point on the cortex or in the path resulted in vascular injury; it may be the key cause of ischemic events during DBS procedures.

Size and shape matter: The impact of voxel geometry on the identification of small nuclei

How, and to what extent do size and shape of a voxel measured with magnetic resonance imaging (MRI) affect the ability to visualize small brain nuclei? Despite general consensus that voxel geometry affects volumetric properties of regions of interest, particularly those of small brain nuclei, no quantitative data on the influence of voxel size and shape on labeling accuracy is available. Using simulations, we investigated the selective influence of voxel geometry by reconstructing simulated ellipsoid structures with voxels varying in shape and size. For each reconstructed ellipsoid, we calculated differences in volume and similarity between the labeled volume and the predefined dimensions of the ellipsoid. Probability functions were derived from one or two individual raters and a simulated ground truth for reference. As expected, larger voxels (i.e., coarser resolution) and increasing anisotropy results in increased deviations of both volume and shape measures, which is of particular relevance for small brain structures. Our findings clearly illustrate the anatomical inaccuracies introduced by the application of large and/or anisotropic voxels. To ensure deviations occur within the acceptable range (Dice coefficient scores; DCS > 0.75, corresponding to < 57% volume deviation), the volume of isotropic voxels should not exceed 5% of the total volume of the region of interest. When high accuracy is required (DCS > 0.90, corresponding to a < 19% volume deviation), the volumes of isotropic voxels should not exceed 0.08%, of the total volume. Finally, when large anisotropic factors (>3) are used, and the ellipsoid is orthogonal to the slice axes, having its long axis in the imaging plane, the voxel volume should not exceed 0.005% of the total volume. This allows sufficient compensation of anisotropy effects, in order to reach accuracy in the acceptable range (DCS > 0.75, corresponding to >57% volume deviation).

Numerical Simulations of Realistic Lead Trajectories and an Experimental Verification Support the Efficacy of Parallel Radiofrequency Transmission to Reduce Heating of Deep Brain Stimulation Implants during MRI

Patients with deep brain stimulation (DBS) implants may be subject to heating during MRI due to interaction with excitatory radiofrequency (RF) fields. Parallel RF transmit (pTx) has been proposed to minimize such RF-induced heating in preliminary proof-of-concept studies. The present work evaluates the efficacy of pTx technique on realistic lead trajectories obtained from nine DBS patients. Electromagnetic simulations were performed using 4- and 8-element pTx coils compared with a standard birdcage coil excitation using patient models and lead trajectories obtained by segmentation of computed tomography data. Numerical optimization was performed to minimize local specific absorption rate (SAR) surrounding the implant tip while maintaining spatial homogeneity of the transmitted RF magnetic field (B₁⁺), by varying the input amplitude and phase for each coil element. Local SAR was significantly reduced at the lead tip with both 4-element and 8-element pTx (median decrease of 94% and 97%, respectively), whereas the median coefficient of spatial variation of B₁⁺ inhomogeneity was moderately increased (30% for 4-element pTx and 20% for 8-element pTx) compared to that of the birdcage coil (17%). Furthermore, the efficacy of optimized 4-element pTx was verified experimentally by imaging a head phantom that included a wire implanted to approximate the worst-case lead trajectory for localized heating, based on the simulations. Negligible temperature elevation was observed at the lead tip, with reasonable image uniformity in the surrounding region. From this experiment and the simulations based on nine DBS patient models, optimized pTx provides a robust approach to minimizing local SAR with respect to lead trajectory.

Numerical Simulations of Realistic Lead Trajectories and an Experimental Verification Support the Efficacy of Parallel Radiofrequency Transmission to Reduce Heating of Deep Brain Stimulation Implants during MRI

Patients with deep brain stimulation (DBS) implants may be subject to heating during MRI due to interaction with excitatory radiofrequency (RF) fields. Parallel RF transmit (pTx) has been proposed to minimize such RF-induced heating in preliminary proof-of-concept studies. The present work evaluates the efficacy of pTx technique on realistic lead trajectories obtained from nine DBS patients. Electromagnetic simulations were performed using 4- and 8-element pTx coils compared with a standard birdcage coil excitation using patient models and lead trajectories obtained by segmentation of computed tomography data. Numerical optimization was performed to minimize local specific absorption rate (SAR) surrounding the implant tip while maintaining spatial homogeneity of the transmitted RF magnetic field (B₁⁺), by varying the input amplitude and phase for each coil element. Local SAR was significantly reduced at the lead tip with both 4-element and 8-element pTx (median decrease of 94% and 97%, respectively), whereas the median coefficient of spatial variation of B₁⁺ inhomogeneity was moderately increased (30% for 4-element pTx and 20% for 8-element pTx) compared to that of the birdcage coil (17%). Furthermore, the efficacy of optimized 4-element pTx was verified experimentally by imaging a head phantom that included a wire implanted to approximate the worst-case lead trajectory for localized heating, based on the simulations. Negligible temperature elevation was observed at the lead tip, with reasonable image uniformity in the surrounding region. From this experiment and the simulations based on nine DBS patient models, optimized pTx provides a robust approach to minimizing local SAR with respect to lead trajectory.

White Matter Changes Along the Electrode Lead in Patients Treated With Deep Brain Stimulation

Introduction: Deep brain stimulation (DBS) is an established treatment for various movement disorders. There is little data available about the potential damage to brain parenchyma through DBS treatment. The objective of this study was to investigate the occurrence of signal changes on magnetic resonance imaging (MRI) in patients treated with DBS.

Methods: We retrospectively analyzed MRI scans of 30 DBS patients (21 patients with Parkinson's disease, 3 patients with dystonia and 6 patients with tremor) that had undergone additional MRI scans after DBS surgery (ranging from 2 months to 8 years). Axial T2 sequences were analyzed by two raters using a standardized lesion mapping procedure.

Results: 26 out of 30 analyzed patients showed hyperintense white matter changes surrounding the DBS lead (mean volume = 2.43 ml). Lesions were prominent along the upper half of the electrode lead within the subcortical white matter, with no abnormalities along the lower lead. Their volume was significantly correlated to the time from surgery to MRI and to the number of microelectrodes used in surgery, but was independent from underlying disease (Parkinson's disease, dystonia, tremor), target structure (STN, GPi, VIM), demographical data, or cardiovascular risk factors.

Discussion: White matter changes along the electrode leads in DBS patients are a frequent finding. These changes seem to evolve with certain latency after surgery and might be radiologically classified as a gliosis. Our findings identify the number of intraoperatively used microelectrodes as a risk factor in the formation of gliosis. Therefore, mechanical damage at the time of surgery and an individual tissue response might contribute to their evolution. Further studies are needed to define the exact mechanisms and their clinical impact.

Cardiac balanced steady-state free precession MRI at 0.35 T: a comparison study with 1.5 T

Background

While low-field MRI is disadvantaged by a reduced signal-to-noise ratio (SNR) compared to higher fields, it has a number of useful features such as decreased SAR and shorter T1, and has shown promise for diagnostic imaging. This study demonstrates the feasibility of cardiac balanced steady-state free precession (bSSFP) MRI at 0.35 T and compares cardiac bSSFP MRI images at 0.35 T with those at 1.5 T.

Methods

Cardiac images were acquired in 7 healthy volunteers using an ECG-gated bSSFP cine sequence on a 0.35 T superconducting MR system as well as a clinical 1.5 T system. Blood and myocardium SNR and contrast-to-noise ratio (CNR) were computed. Subjective image scoring was used to compare the image quality between 0.35 and 1.5 T.

Results

Cardiac images at 0.35 T were successfully acquired in all volunteers. While the 0.35 T images were noisier than those at 1.5 T, blood, myocardium and papillary muscles could be clearly delineated. At 0.35 T, bSSFP images were acquired at flip angles as high as 150°. Maximum CNR was achieved at 130°. Image quality scoring showed that while at lower flip angles, the 0.35 T images had poorer quality than the 1.5 T, but with flip angles of 110 and 130, the image quality at 0.35 T had scores similar to those at 1.5 T.

Conclusions

This study demonstrates that cardiac bSSFP imaging is highly feasible at 0.35 T.

Thermo-Acoustic Ultrasound for Detection of RF-Induced Device Lead Heating in MRI

Patients who have implanted medical devices with long conductive leads are often restricted from receiving MRI scans due to the danger of RF-induced heating near the lead tips. Phantom studies have shown that this heating varies significantly on a case-by-case basis, indicating that many patients with implanted devices can receive clinically useful MRI scans without harm. However, the difficulty of predicting RF-induced lead tip heating prior to scanning prevents numerous implant recipients from being scanned. Here, we demonstrate that thermo-acoustic ultrasound (TAUS) has the potential to be utilized for a pre-scan procedure assessing the risk of RF-induced lead tip heating in MRI. A system was developed to detect TAUS signals by four different TAUS acquisition methods. We then integrated this system with an MRI scanner and detected a peak in RF power absorption near the tip of a model lead when transmitting from the scanner's body coil. We also developed and experimentally validated simulations to characterize the thermo-acoustic signal generated near lead tips. These results indicate that TAUS is a promising method for assessing RF implant safety, and with further development, a TAUS pre-scan could allow many more patients to have access to MRI scans of significant clinical value.

Ultrahigh-Magnitude Brain Magnetic Resonance Imaging Scan on Rhesus Monkeys With Implanted Deep Brain Stimulation Hardware

BACKGROUND

Patients with implanted deep brain stimulation (DBS) hardware are prohibited from undergoing magnetic resonance imaging (MRI) scans at magnitudes greater than 1.5 T to avoid potential MRI-related heating injury. Whether DBS devices are compatible with higher field MRI scanning is unknown. This study aimed to investigate whether 7.0 T and 3.0 T MRI scans can be safely performed on rhesus monkeys with implanted DBS devices.

METHODS

Eight male rhesus monkeys were included in this study and stereotactically implanted with DBS devices in the left anterior thalamus. Two weeks after DBS device implantation, 7.0 T and 3.0 T MRI scans were performed. The monkeys were observed for 72 hours. After explantation of the DBS system, 7.0 T MRI was repeated to determine potential lesions. Hematoxylin and eosin staining and transmission electron microscopy were conducted to assess pathological alterations.

RESULTS

In both groups, the monkeys exhibited no behavioral changes related to neurological deficits. Post-explantation MRI showed no malacia foci surrounding the DBS tracks. Additionally, neither hematoxylin and eosin staining nor transmission electron microscopy showed clear injury near the DBS leads.

CONCLUSION

These results indicate that no obvious heating injury was induced in the tissue surrounding the DBS leads by the 7.0 T and 3.0 T MRI scans. Although the results of this study may not be generalizable, these data suggest that patients with implanted DBS devices can undergo even 7.0 T MRI without risk of brain injury.

Technical challenges and safety of magnetic resonance imaging with in situ neuromodulation from spine to brain

PURPOSE

This review summarises the need for MRI with in situ neuromodulation, the key safety challenges and how they may be mitigated, and surveys the current status of MRI safety for the main categories of neuro-stimulation device, including deep brain stimulation, vagus nerve stimulation, sacral neuromodulation, spinal cord stimulation systems, and cochlear implants.

REVIEW SUMMARY

When neuro-stimulator systems are introduced into the MRI environment a number of hazards arise with potential for patient harm, in particular the risk of thermal injury due to MRI-induced heating. For many devices however, safe MRI conditions can be determined, and MRI safely performed, albeit with possible compromise in anatomical coverage, image quality or extended acquisition time.

CONCLUSIONS

The increasing availability of devices conditional for 3 T MRI, whole-body transmit imaging, and imaging in the on-stimulation condition, will be of significant benefit to the growing population of patients benefitting from neuromodulation therapy, and open up new opportunities for functional imaging research.

Construction and modeling of a reconfigurable MRI coil for lowering SAR in patients with deep brain stimulation implants

Post-operative MRI of patients with deep brain simulation (DBS) implants is useful to assess complications and diagnose comorbidities, however more than one third of medical centers do not perform MRIs on this patient population due to stringent safety restrictions and liability risks. A new system of reconfigurable magnetic resonance imaging head coil composed of a rotatable linearly-polarized birdcage transmitter and a close-fitting 32-channel receive array is presented for low-SAR imaging of patients with DBS implants. The novel system works by generating a region with low electric field magnitude and steering it to coincide with the DBS lead trajectory. We demonstrate that the new coil system substantially reduces the SAR amplification around DBS electrodes compared to commercially available circularly polarized coils in a cohort of 9 patient-derived realistic DBS lead trajectories. We also show that the optimal coil configuration can be reliably identified from the image artifact on B₁⁺ field maps. Our preliminary results suggest that such a system may provide a viable solution for high-resolution imaging of DBS patients in the future. More data is needed to quantify safety limits and recommend imaging protocols before the novel coil system can be used on patients with DBS implants.

Local SAR near deep brain stimulation (DBS) electrodes at 64 and 127 MHz: A simulation study of the effect of extracranial loops

PURPOSE

MRI may cause brain tissue around deep brain stimulation (DBS) electrodes to become excessively hot, causing lesions. The presence of extracranial loops in the DBS lead trajectory has been shown to affect the specific absorption rate (SAR) of the radiofrequency energy at the electrode tip, but experimental studies have reported controversial results. The goal of this study was to perform a systematic numerical study to provide a better understanding of the effects of extracranial loops in DBS leads on the local SAR during MRI at 64 and 127 MHz.

METHODS

A total of 160 numerical simulations were performed on patient-derived data, in which relevant factors including lead length and trajectory, loop location and topology, and frequency of MRI radiofrequency (RF) transmitter were assessed.

RESULTS

Overall, the presence of extracranial loops reduced the local SAR in the tissue around the DBS tip compared with straight trajectories with the same length. SAR reduction was significantly larger at 127 MHz compared with 64 MHz. SAR reduction was significantly more sensitive to variable loop parameters (eg, topology and location) at 127 MHz compared with 64 MHz.

CONCLUSION

Lead management strategies could exist that significantly reduce the risks of 3 Tesla (T) MRI for DBS patients. Magn Reson Med 78:1558-1565, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Optimized, Minimal Specific Absorption Rate MRI for High-Resolution Imaging in Patients with Implanted Deep Brain Stimulation Electrodes

BACKGROUND AND PURPOSE

Obtaining high-resolution brain MR imaging in patients with a previously implanted deep brain stimulator has been challenging and avoided by many centers due to safety concerns relating to implantable devices. We present our experience with a practical clinical protocol at 1.5T by using 2 magnet systems capable of achieving presurgical quality imaging in patients undergoing bilateral, staged deep brain stimulator insertion.

MATERIALS AND METHODS

Protocol optimization was performed to minimize the specific absorption rate while providing image quality necessary for adequate surgical planning of the second electrode placement. We reviewed MR imaging studies performed with a minimal specific absorption rate protocol in patients with a deep brain stimulator in place at our institution between February 1, 2012, and August 1, 2015. Images were reviewed by a neuroradiologist and a functional neurosurgeon. Image quality was qualitatively graded, and the presence of artifacts was noted.

RESULTS

Twenty-nine patients (22 with Parkinson disease, 6 with dystonia, 1 with essential tremor) were imaged with at least 1 neuromodulation implant in situ. All patients were imaged under general anesthesia. There were 25 subthalamic and 4 globus pallidus implants. Nineteen patients were preoperative for the second stage of bilateral deep brain stimulator placement; 10 patients had bilateral electrodes in situ and were being imaged for other neurologic indications, including lead positioning. No adverse events occurred during or after imaging. Mild device-related local susceptibility artifacts were present in all studies, but they were not judged to affect overall image quality. Minimal aliasing artifacts were seen in 7, and moderate motion, in 4 cases on T1WI only. All preoperative studies were adequate for guidance of a second deep brain stimulator placement.

CONCLUSIONS

An optimized MR imaging protocol that minimizes the specific absorption rate can be used to safely obtain high-quality images in patients with previously implanted deep brain stimulators, and these images are adequate for surgical guidance.

Imaging of Anterior Nucleus of Thalamus Using 1.5T MRI for Deep Brain Stimulation Targeting in Refractory Epilepsy

BACKGROUND

Deep brain stimulation (DBS) of the anterior nucleus of thalamus (ANT) is an evolving treatment option in refractory focal epilepsy. Due to poor visualization of ANT in traditional MRI sequences used for movement disorder surgery, targeting of ANT is mainly based on stereotactic atlas information. Sophisticated 3T MRI methods enable visualization of ANT, but 1.5T MRI is still preferred or more readily available in a large number of centers performing DBS.

OBJECTIVE

In the present study, we sought to determine whether ANT could be adequately visualized at 1.5T MRI pre- and postoperatively using imaging techniques similar to the ones visualizing ANT in 3T MRI. A total of 15 MRI examinations with short tau inversion recovery (STIR) and T1-weighted magnetization prepared gradient echo (MPRAGE) images were performed to visualize ANT in nonepileptic subjects (n = 2), patients with vagus nerve stimulator (VNS) (n = 3), stereotactic MRI (n = 3), patients with ANT-DBS (n = 7).

RESULTS

ANT was distinctly visualized in STIR and T1-weighted MPRAGE images in patients without implanted stimulators, with Leksell stereotactic frame and with fully implanted VNS. Postoperative 1.5T MRI was able to demonstrate some of the anatomical landmarks around ANT enabling assessment of electrode contact locations.

CONCLUSIONS

The visualization of ANT is possible in preoperative 1.5T MRI enabling direct targeting of ANT all examined situations. The use of indirect targeting and its inherent potential for lead misplacement due to anatomical variation may be avoided using these MRI methods. Furthermore, postoperative MRI with STIR and T1-weighted MPRAGE images enable detailed postoperative assessment of contact locations.

Feasibility of using linearly polarized rotating birdcage transmitters and close-fitting receive arrays in MRI to reduce SAR in the vicinity of deep brain simulation implants

PURPOSE

MRI of patients with deep brain stimulation (DBS) implants is strictly limited due to safety concerns, including high levels of local specific absorption rate (SAR) of radiofrequency (RF) fields near the implant and related RF-induced heating. This study demonstrates the feasibility of using a rotating linearly polarized birdcage transmitter and a 32-channel close-fit receive array to significantly reduce local SAR in MRI of DBS patients.

METHODS

Electromagnetic simulations and phantom experiments were performed with generic DBS lead geometries and implantation paths. The technique was based on mechanically rotating a linear birdcage transmitter to align its zero electric-field region with the implant while using a close-fit receive array to significantly increase signal to noise ratio of the images.

RESULTS

It was found that the zero electric-field region of the transmitter is thick enough at 1.5 Tesla to encompass DBS lead trajectories with wire segments that were up to 30 degrees out of plane, as well as leads with looped segments. Moreover, SAR reduction was not sensitive to tissue properties, and insertion of a close-fit 32-channel receive array did not degrade the SAR reduction performance.

CONCLUSION

The ensemble of rotating linear birdcage and 32-channel close-fit receive array introduces a promising technology for future improvement of imaging in patients with DBS implants. Magn Reson Med 77:1701-1712, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Intraoperative MRI for optimizing electrode placement for deep brain stimulation of the subthalamic nucleus in Parkinson disease

OBJECT

The degree of clinical improvement achieved by deep brain stimulation (DBS) is largely dependent on the accuracy of lead placement. This study reports on the evaluation of intraoperative MRI (iMRI) for adjusting deviated electrodes to the accurate anatomical position during DBS surgery and acute intracranial changes.

METHODS

Two hundred and six DBS electrodes were implanted in the subthalamic nucleus (STN) in 110 patients with Parkinson disease. All patients underwent iMRI after implantation to define the accuracy of lead placement. Fifty-six DBS electrode positions in 35 patients deviated from the center of the STN, according to the result of the initial postplacement iMRI scans. Thus, we adjusted the electrode positions for placement in the center of the STN and verified this by means of second or third iMRI scans. Recording was performed in adjusted parameters in the x-, y-, and z-axes.

RESULTS

Fifty-six (27%) of 206 DBS electrodes were adjusted as guided by iMRI. Electrode position was adjusted on the basis of iMRI 62 times. The sum of target coordinate adjustment was −0.5 mm in the x-axis, −4 mm in the y-axis, and 15.5 mm in the z-axis; the total of distance adjustment was 74.5 mm in the x-axis, 88 mm in the y-axis, and 42.5 mm in the z-axis. After adjustment with the help of iMRI, all electrodes were located in the center of the STN. Intraoperative MRI revealed 2 intraparenchymal hemorrhages in 2 patients, brain shift in all patients, and leads penetrating the lateral ventricle in 3 patients.

CONCLUSIONS

The iMRI technique can guide surgeons as they adjust deviated electrodes to improve the accuracy of implanting the electrodes into the correct anatomical position. The iMRI technique can also immediately demonstrate acute changes such as hemorrhage and brain shift during DBS surgery.

Motor and Nonmotor Circuitry Activation Induced by Subthalamic Nucleus Deep Brain Stimulation in Patients With Parkinson Disease: Intraoperative Functional Magnetic Resonance Imaging for Deep Brain Stimulation

OBJECTIVE

To test the hypothesis suggested by previous studies that subthalamic nucleus (STN) deep brain stimulation (DBS) in patients with Parkinson disease would affect the activity of motor and nonmotor networks, we applied intraoperative functional magnetic resonance imaging (fMRI) to patients receiving DBS.

PATIENTS AND METHODS

Ten patients receiving STN DBS for Parkinson disease underwent intraoperative 1.5-T fMRI during high-frequency stimulation delivered via an external pulse generator. The study was conducted between January 1, 2013, and September 30, 2014.

RESULTS

We observed blood oxygen level-dependent (BOLD) signal changes (false discovery rate <0.001) in the motor circuitry (including the primary motor, premotor, and supplementary motor cortices; thalamus; pedunculopontine nucleus; and cerebellum) and in the limbic circuitry (including the cingulate and insular cortices). Activation of the motor network was observed also after applying a Bonferroni correction (P<.001) to the data set, suggesting that across patients, BOLD changes in the motor circuitry are more consistent compared with those occurring in the nonmotor network.

CONCLUSION

These findings support the modulatory role of STN DBS on the activity of motor and nonmotor networks and suggest complex mechanisms as the basis of the efficacy of this treatment modality. Furthermore, these results suggest that across patients, BOLD changes in the motor circuitry are more consistent than those in the nonmotor network. With further studies combining the use of real-time intraoperative fMRI with clinical outcomes in patients treated with DBS, functional imaging techniques have the potential not only to elucidate the mechanisms of DBS functioning but also to guide and assist in the surgical treatment of patients affected by movement and neuropsychiatric disorders.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01809613.

Evaluation of electrode position in deep brain stimulation by image fusion (MRI and CT)

INTRODUCTION

Imaging has an essential role in the evaluation of correct positioning of electrodes implanted for deep brain stimulation (DBS). Although MRI offers superior anatomic visualization of target sites, there are safety concerns in patients with implanted material; imaging guidelines are inconsistent and vary. The fusion of postoperative CT with preoperative MRI images can be an alternative for the assessment of electrode positioning. The purpose of this study was to assess the accuracy of measurements realized on fused images (acquired without a stereotactic frame) using a manufacturer-provided software.

METHODS

Data from 23 Parkinson's disease patients who underwent bilateral electrode placement for subthalamic nucleus (STN) DBS were acquired. Preoperative high-resolution T2-weighted sequences at 3 T, and postoperative CT series were fused using a commercially available software. Electrode tip position was measured on the obtained images in three directions (in relation to the midline, the AC-PC line and an AC-PC line orthogonal, respectively) and assessed in relation to measures realized on postoperative 3D T1 images acquired at 1.5 T.

RESULTS

Mean differences between measures carried out on fused images and on postoperative MRI lay between 0.17 and 0.97 mm.

CONCLUSION

Fusion of CT and MRI images provides a safe and fast technique for postoperative assessment of electrode position in DBS.

Role of radiology in central nervous system stimulation

Central nervous system (CNS) stimulation is becoming increasingly prevalent. Deep brain stimulation (DBS) has been proven to be an invaluable treatment for movement disorders and is also useful in many other neurological conditions refractory to medical treatment, such as chronic pain and epilepsy. Neuroimaging plays an important role in operative planning, target localization and post-operative follow-up. The use of imaging in determining the underlying mechanisms of DBS is increasing, and the dependence on imaging is likely to expand as deep brain targeting becomes more refined. This article will address the expanding role of radiology and highlight issues, including MRI safety concerns, that radiologists may encounter when confronted with a patient with CNS stimulation equipment in situ.

Lead-DBS: a toolbox for deep brain stimulation electrode localizations and visualizations

To determine placement of electrodes after deep brain stimulation (DBS) surgery, a novel toolbox that facilitates both reconstruction of the lead electrode trajectory and the contact placement is introduced. Using the toolbox, electrode placement can be reconstructed and visualized based on the electrode-induced artifacts on post-operative magnetic resonance (MR) or computed tomography (CT) images. Correct electrode placement is essential for efficacious treatment with DBS. Post-operative knowledge about the placement of DBS electrode contacts and trajectories is a promising tool for clinical evaluation of DBS effects and adverse effects. It may help clinicians in identifying the best stimulation contacts based on anatomical target areas and may even shorten test stimulation protocols in the future. Fifty patients that underwent DBS surgery were analyzed in this study. After normalizing the post-operative MR/CT volumes into standard Montreal Neurological Institute (MNI)-stereotactic space, electrode leads (n=104) were detected by a novel algorithm that iteratively thresholds each axial slice and isolates the centroids of the electrode artifacts within the MR/CT-images (MR only n=32, CT only n=10, MR and CT n=8). Two patients received four, the others received two quadripolar DBS leads bilaterally, summing up to a total of 120 lead localizations. In a second reconstruction step, electrode contacts along the lead trajectories were reconstructed by using templates of electrode tips that had been manually created beforehand. Reconstructions that were made by the algorithm were finally compared to manual surveys of contact localizations. The algorithm was able to robustly accomplish lead reconstructions in an automated manner in 98% of electrodes and contact reconstructions in 69% of electrodes. Using additional subsequent manual refinement of the reconstructed contact positions, 118 of 120 electrode lead and contact reconstructions could be localized using the toolbox. Taken together, the toolbox presented here allows for a precise and fast reconstruction of DBS contacts by proposing a semi-automated procedure. Reconstruction results can be directly exported to two- and three-dimensional views that show the relationship between DBS contacts and anatomical target regions. The toolbox is made available to the public in form of an open-source MATLAB repository.

Magnetic resonance imaging conditionally safe neurostimulation leads: investigation of the maximum safe lead tip temperature

BACKGROUND

Magnetic resonance imaging (MRI) is preferred for imaging the central nervous system (CNS). An important hazard for neurostimulation patients is heating at the electrode interface induced, for example, by 64-MHz radiofrequency (RF) magnetic fields of a 1.5T scanner.

OBJECTIVE

We performed studies to define the thermal dose (time and temperature) that would not cause symptomatic neurological injury.

METHODS

Approaches included animal studies where leads with temperature probes were implanted in the brain or spine of sheep and exposed to RF-induced temperatures of 37 °C to 49 °C for 30 minutes. Histopathological examinations were performed 7 days after recovery. We also reviewed the threshold for RF lesions in the CNS, and for CNS injury from cancer hyperthermia. Cumulative equivalent minutes at 43 °C was used to normalize the data to exposure times and temperatures expected during MRI.

RESULTS

Deep brain and spinal RF heating up to 43 °C for 30 minutes produced indistinguishable effects compared with 37 °C controls. Exposures greater than 43 °C for 30 minutes produced temperature-dependent, localized thermal damage. These results are consistent with limits on hyperthermia exposure to 41.8 °C for 60 minutes in patients who have cancer and with the reversibility of low-temperature and short-duration trial heating during RF lesion procedures.

CONCLUSION

A safe temperature for induced lead heating is 43 °C for 30 minutes. MRI-related RF heating above 43 °C or longer than 30 minutes may be associated with increased risk of clinically evident thermal damage to neural structures immediately surrounding implanted leads. The establishment of a thermal dose limit is a first step toward making specific neurostimulation systems conditionally safe during MRI procedures.

Pathological alterations and stress responses near DBS electrodes after MRI scans at 7.0T, 3.0T and 1.5T: an in vivo comparative study

OBJECTIVE

The purpose of this study was to investigate the pathological alterations and the stress responses around deep brain stimulation (DBS) electrodes after magnetic resonance imaging (MRI) scans at 7.0T, 3.0T and 1.5T.

MATERIALS AND METHODS

DBS devices were stereotactically implanted into the brains of New Zealand rabbits, targeting the left nucleus ventralis posterior thalami, while on the right side, a puncture passage pointing to the same target was made. MRI scans at 7.0T, 3.0T and 1.5T were performed using transmit/receive head coils. The pathological alterations of the surrounding tissue were evaluated by hematoxylin and eosin staining (H&E staining) and transmission electron microscopy (TEM). The levels of the 70 kDa heat shock protein (HSP-70), Neuronal Nuclei (NeuN) and Caspase-3 were determined by western-blotting and quantitative polymerase chain reaction (QPCR) to assess the stress responses near the DBS electrodes.

RESULTS

H&E staining and TEM showed that the injury around the DBS electrodes was featured by a central puncture passage with gradually weakened injurious alterations. Comparisons of the injury across the groups manifested similar pathological alterations near the DBS electrodes in each group. Moreover, western-blotting and QPCR assay showed that the level of HSP-70 was not elevated by MRI scans (p>0.05), and the levels of NeuN and Caspase-3 were equal in each group, regardless of the field strengths applied (p>0.05).

CONCLUSIONS

Based on these findings, it is reasonable to conclude that in this study the MRI scans at multiple levels failed to induce additional tissue injury around the DBS electrodes. These preliminary data furthered our understanding of MRI-related DBS heating and encouraged revisions of the current MRI guidelines for patients with DBS devices.

Low-power inversion recovery MRI preserves brain tissue contrast for patients with Parkinson disease with deep brain stimulators

BACKGROUND AND PURPOSE

Fast spin-echo short τ inversion recovery sequences have been very useful for MR imaging-guided deep brain stimulation procedures in Parkinson disease. However, high-quality fast spin-echo imaging deposits significant heat, exceeding FDA-approved limits when patients already have undergone deep brain stimulation and need a second one or a routine brain MR imaging for neurologic indications. We have developed a STIR sequence with an ultra-low specific absorption rate that meets hardware limitations and produces adequate tissue contrast in cortical and subcortical brain tissues for deep brain stimulation recipients.

MATERIALS AND METHODS

Thirteen patients with medically refractory Parkinson disease who qualified for deep brain stimulation were imaged at 1.5T with a fast spin-echo short τ inversion recovery sequence modified to meet conditional MR imaging hardware and specific absorption rate restrictions. Tissue contrast-to-noise ratios and implant localization were objectively and subjectively compared by 2 neuroradiologists, and image quality for surgical planning was assessed by a neurosurgeon for high and low specific absorption rate images.

RESULTS

The mean contrast-to-noise ratio for cerebral tissues without including the contrast-to-noise ratio for ventricular fluid was 35 and 31 for high and low specific absorption rate images. Subjective ratings for low specific absorption rate tissue contrast in 77% of patients were identical to (and in a few cases higher than) those of high specific absorption rate contrast, while the neurosurgical coordinates for fusing the stereotactic atlas with low specific absorption rate MR imaging were equivalent to those of the high specific absorption rate for 69% of patients.

CONCLUSIONS

Patients with Parkinson disease who have already had a deep brain stimulation face a risk of neural injury if routine, high specific absorption rate MR imaging is performed. Our modified fast spin-echo short τ inversion recovery sequence conforms to very conservative radiofrequency safety limits, while it maintains high tissue contrast for presurgical planning, postsurgical assessment, and radiologic evaluations with greater confidence for radiofrequency safety.

Neural stimulators: a guide to imaging and postoperative appearances

Implantable neural stimulators have been developed to aid patients with debilitating neurological conditions that are not amenable to other therapies. The aim of this article is to improve understanding of correct anatomical placement as well as the relevant imaging methods used to assess these devices. Potential complications following their insertion and an overview of the current indications and potential mechanism of action of these devices is provided.

Utilizing fast spin echo MRI to reduce image artifacts and improve implant/tissue interface detection in refractory Parkinson's patients with deep brain stimulators

Introduction. In medically refractory Parkinson's disease (PD) deep-brain stimulation (DBS) is an effective therapeutic tool. Postimplantation MRI is important in assessing tissue damage and DBS lead placement accuracy. We wanted to identify which MRI sequence can detect DBS leads with smallest artifactual signal void, allowing better tissue/electrode edge conspicuity. Methods. Using an IRB approved protocol 8 advanced PD patients were imaged within MR conditional safety guidelines at low RF power (SAR ≤ 0.1 W/kg) in coronal plane at 1.5T by various sequences. The image slices were subjectively evaluated for diagnostic quality and the lead contact diameters were compared to identify a sequence least affected by metallic leads. Results and Discussion. Spin echo and fast spin echo based low SAR sequences provided acceptable image quality with comparable image blooming (enlargement) of stimulator leads. The mean lead diameters were 2.2 ± 0.1 mm for 2D, 2.1 ± 0.1 mm for 3D, and 4.0 ± 0.2 mm for 3D MPRAGE sequence. Conclusion. Low RF power spin echo and fast spin echo based 2D and 3D FSE sequences provide acceptable image quality adjacent to DBS leads. The smallest artifactual blooming of stimulator leads is present on 3D FSE while the largest signal void appears in the 3D MPRAGE sequence.

Three-dimensional brain MRI for DBS patients within ultra-low radiofrequency power limits

BACKGROUND

For patients with deep brain stimulators (DBS), local absorbed radiofrequency (RF) power is unknown and is much higher than what the system estimates. We developed a comprehensive, high-quality brain magnetic resonance imaging (MRI) protocol for DBS patients utilizing three-dimensional (3D) magnetic resonance sequences at very low RF power.

METHODS

Six patients with DBS were imaged (10 sessions) using a transmit/receive head coil at 1.5 Tesla with modified 3D sequences within ultra-low specific absorption rate (SAR) limits (0.1 W/kg) using T2 , fast fluid-attenuated inversion recovery (FLAIR) and T1 -weighted image contrast. Tissue signal and tissue contrast from the low-SAR images were subjectively and objectively compared with routine clinical images of six age-matched controls.

RESULTS

Low-SAR images of DBS patients demonstrated tissue contrast comparable to high-SAR images and were of diagnostic quality except for slightly reduced signal.

CONCLUSIONS

Although preliminary, we demonstrated diagnostic quality brain MRI with optimized, volumetric sequences in DBS patients within very conservative RF safety guidelines offering a greater safety margin.

Magnetic resonance imaging safety of deep brain stimulator devices

Magnetic resonance imaging (MRI) has become the standard of care for the evaluation of different neurological disorders of the brain and spinal cord due to its multiplanar capabilities and excellent soft tissue resolution. With the large and increasing population of patients with implanted deep brain stimulation (DBS) devices, a significant proportion of these patients with chronic neurological diseases require evaluation of their primary neurological disease processes by MRI. The presence of an implanted DBS device in a magnetic resonance environment presents potential hazards. These include the potential for induction of electrical currents or heating in DBS devices, which can result in neurological tissue injury, magnetic field-induced device migration, or disruption of the operational aspects of the devices. In this chapter, we review the basic physics of potential interactions of the MRI environment with implanted DBS devices, summarize results from phantom studies and clinical series, and discuss present recommendations for safe MRI in patients with implanted DBS devices.